1. Obtain focused urinary history emphasizing character and duration of
lower urinary symptoms, remembering that the presence of obstructive or
irritative voiding symptoms is not diagnostic of urinary retention.
Query the patient about episodes of acute urinary retention (complete
inability to void) or chronic rentention (documented elevated postvoid
residual volumes).A focused nursing history provides clues to the likely etiology of retention and its management (Gray, 2000a).

3. Perform a focused physical assessment or review the results of a
recent physical including perineal skin integrity; neurological
examination, inspection, percussion, and palpation of the lower abdomen
for obvious bladder distension; neurological examination including
perineal skin sensation and the bulbocavernosus reflex; and vaginal
vault examination in women/digital rectal examination in men.The physical assessment provides clues to the likely etiology of urinary retention and its management.

4. Determine the urinary residual volume by catheterizing the patient
immediately after urination, or by obtaining a bladder ultrasound
following micturition.Catheterization provides the most accurate method to determine
urinary residual volume, but the procedure is invasive, carries a risk
of infection, and may be uncomfortable for the patient. A bladder
ultrasound is not as accurate as catheterization; nonetheless it is
adequate for clinical judgments and is noninvasive (Bent, Nahhas,
Mclennan, 1997; Lewis, 1995).

5. Complete a bladder log, including patterns of urine elimination,
patterns of urine loss (if present), nocturia, and volume and type of
fluids consumed for a period of 3 to 7 days.The bladder log provides an objective verification of urine
elimination patterns and allows comparison between fluids consumed and
urinary output in a 24-hour period (Nygaard, Holcomb, 2000).

7. Assess the severity of retention and its impact on quality of life using a symptom score such as the AUA ProstateSymptom Score (BPH Guideline Panel, 1994). A symptom allows rating of
the severity of obstructive and irritative symptoms, providing baseline
assessment and evaluation of the efficacy of management.

8. Teach the patient with mild to moderate obstructive symptoms to
double void by urinating, resting in the rest room for 3 to 5 minutes,
then making a second effort to urinate.Double voiding promotes more efficient bladder evacuation by allowing
the detrusor to contract initially, then rest and contract again (Gray,
2000b).

9. Teach the patient with urinary retention and infrequent voiding to urinate by the clock.Timed or scheduled voiding may reduce urinary retention by preventing bladder overdistension (Gray, 2000b).

Discussing voiding problems with a health care provider before beginning any new prescription medications

After prolonged exposure to cool weather, warming the body before attempting to urinate

Avoiding overfilling the bladder by adhering to regular urination patterns and refraining from excessive intake of alcohol

These manageable factors predispose the patient to acute urinary
retention by overdistending the bladder and compromising detrusor
contraction strength, or by increasing outlet resistance (Gray, 2000b).

11. Teach the elderly male client with BPH to self-administer
finasteride or an alpha-adrenergic blocking agent such as doxazosin,
terazosin, or tamsulosin as directed. Provide careful instruction
concerning the dosage, administration schedule, and side effects of
these drugs, including possible adverse effects when multiple doses are
inadvertently missed.Finasterid is a 5-alpha reductase inhibitor that reduces the risk of
acute urinary retention when taken by men with BPH for a prolonged
period (McConnell et al, 1998). The magnitude of obstruction associated
with BPH is also reduced by routine administration of alpha-adrenergic
blocking agents including tamsulosin, terazosin, or doxazosin. However,
these agents must be taken regularly to reduce the risk of side effects,
including postural hypotension (Narayan, Tewari, 1998; Lepor et al,
1997, 1998).

12. Teach the client who is unable to void specific strategies to manage this potential medical emergency including:

Drinking a cup of hot tea or coffee

Attempting urination in complete privacy

Placing the feet solidly on the floor

If unable to void using these strategies, taking a warm sitz bath or
shower and voiding (if possible) while still in the tub or the shower

If unable to void within 6 hours, or if bladder distension is producing significant pain, seeking urgent or emergency care

A warm cup of coffee or tea stimulates the bladder and may promote
voiding. Attempting urination in complete privacy and placing the feet
solidly on the floor help relax the pelvic muscles and may encourage
voiding. Warm water also stimulates the bladder and may produce voiding,
while the cooling experienced by leaving the tub or shower may again
inhibit the bladder (Gray, 2000b).
13. Remove the indwelling urethral catheter at midnight in the
hospitalized patient to reduce the risk of acute urinary retention.Removal of indwelling catheters offers several advantages to morning
removal, including a larger initial voided volume (Crowe et al, 1994) or
early hospital discharge with no increased risk for readmission when
compared with those undergoing morning removal (McDonald, Thompson,
1999).

14. Consult the physician about bladder stimulation in the patient with
urinary retention caused by deficient detrusor contraction strength.Electrical stimulation of the bladder neck has been reported to
provide beneficial results among persons with urinary retention
resulting from deficient detrusor contraction strength (Moore et al,
1993).

16. Advise the person managed by intermittent catheterization that
bacteria are likely to colonize the urine but that this condition does
not indicate a clinically significant urinary tract infection.Bacteriuria frequently occurs in the patient managed by intermittent
catheterization; only symptoms producing infections warrant treatment
(Maynard, Diokno, 1984).

17. Insert an indwelling catheter for the individual with urinary
retention who is not a suitable candidate for intermittent
catheterization.An indwelling catheter provides continuous drainage of urine;
however, the risk of serious urinary complications with prolonged use
are significant (Anson, Gray, 1993; Stickler, Zimakoff, 1994).

18. Advise the person managed by an indwelling catheter that bacteria in
the urine is an almost universal finding after the catheter has
remained in place for a period of weeks or months and that only
symptomatic infections warrant treatment.The indwelling catheter is associated with frequent bacterial
colonization. Most bacteriuria does not produce significant infection
and attempts to eradicate bacteriuria often produce subsequent morbidity
because resistant bacteria are encouraged to reproduce while more
easily managed strains are eradicated (Moore, Rayome, 1995; White,
Ragland, 1995).

Geriatric

1. Aggressively assess the elderly client for urinary retention,
particularly the client with dribbling urinary incontinence, urinary
tract infection, or related conditions.Elderly women (and men) may experience retention of urine of 1500 ml
or more with few or no apparent symptoms; a urinary residual volume and
related assessments are necessary to determine the presence of retention
in this population (Williams, Wallhagen, Dowling, 1993)

2. Assess the elderly client for impaction when urinary retention is documented or suspected.Impaction is a common and reversible factor associated with urine
loss and retention among elderly persons (Urinary Incontinence Guideline
Panel, 1996).

6
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